1
WGU D459 Task 3 Four Steps Tool Actual
Submission Example and Guide 2026/2027 |
Passed Assessment | Step-by-Step Template |
Pass Guarantee
PART 1: STEP ONE – DEFINING THE PROBLEM
1A. What is the problem?
The central venous catheter-associated bloodstream infection (CLABSI) rate in the
Intensive Care Unit (ICU) at Regional Medical Center has increased to 2.8
infections per 1,000 central line days over the past six months, which exceeds the
National Healthcare Safety Network (NHSN) benchmark of 1.0 per 1,000 central
line days and represents a 75% increase from the facility's baseline rate of 1.6 per
1,000 central line days established in the prior year. This elevated infection rate has
resulted in three preventable adverse patient events during the measurement period,
extended ICU length of stay for affected patients by an average of 7.2 days per
case, and generated approximately $132,000 in non-reimbursable costs associated
with treatment of hospital-acquired infections under current Centers for Medicare
& Medicaid Services (CMS) value-based purchasing penalties.
1B. Why is it a problem?
This problem poses significant threats across multiple dimensions of healthcare
quality and organizational performance. From a patient safety perspective,
CLABSIs are associated with mortality rates ranging from 12-25%, cause
substantial patient suffering through prolonged hospitalization and additional
invasive treatments, and represent a preventable harm that contradicts the
fundamental principle of "first, do no harm." For clinical staff, the elevated
infection rate creates moral distress among ICU nurses and physicians who are
committed to evidence-based practice, increases workload burden through complex
infection management protocols, and potentially indicates gaps in adherence to
established central line maintenance bundles that undermine professional practice
, 2
standards. At the organizational level, this problem directly impacts quality metrics
reported to regulatory agencies including The Joint Commission's National Patient
Safety Goal 07.04.01 for catheter-associated infection prevention, triggers financial
penalties under the CMS Hospital-Acquired Condition Reduction Program that can
reduce total Medicare reimbursement by 1%, damages the institution's reputation
in publicly reported Hospital Compare quality scores, and exposes the organization
to potential litigation risk. The Agency for Healthcare Research and Quality
(AHRQ) estimates that each CLABSI costs between $16,550 and $44,000 in
additional healthcare expenditure, none of which is reimbursable under current
payment models, creating a direct negative impact on the organization's financial
sustainability and its capacity to invest in quality improvement infrastructure and
staff development programs.
1C. What is the scope of the problem?
This problem is specifically scoped to the 24-bed medical-surgical intensive care
unit (MSICU) at Regional Medical Center, encompassing all three shifts (day,
evening, and night) and all patient populations requiring central venous access for
a duration exceeding 48 hours. The analysis includes patients with peripherally
inserted central catheters (PICCs), subclavian lines, internal jugular lines, and
femoral lines, but excludes dialysis catheters managed by the nephrology service
and temporary pacing wires managed by cardiothoracic surgery, as these fall under
separate protocols and surveillance systems. The temporal scope covers the six-
month period from October 2026 through March 2027, and geographically is
limited to the MSICU on the fourth floor; other ICU environments such as the
cardiovascular ICU, surgical ICU, and neonatal ICU are not included in this
analysis as they maintain separate nursing leadership, distinct patient populations,
and independent quality improvement structures. The process scope encompasses
central line maintenance practices including dressing changes, cap changes, tubing
changes, access port disinfection, and daily necessity assessments, but does NOT
include initial central line insertion procedures performed by physicians or
advanced practice providers, as insertion technique is governed by a separate
credentialing and competency system under medical staff bylaws. The stakeholder
scope includes ICU registered nurses, ICU nurse managers, infection
preventionists, intensivist physicians, and ICU clinical nurse specialists, but does
, 3
not extend to environmental services, pharmacy, or ancillary departments at this
phase of analysis.
PART 2: STEP TWO – IDENTIFYING CAUSES
2A. Primary Cause (Root Cause):
The fundamental root cause of the elevated CLABSI rate is the absence of a
standardized, enforceable central line maintenance bundle protocol that ensures
consistent adherence to evidence-based practices across all nursing shifts in the
MSICU. A root cause analysis conducted using the "Five Whys" methodology
revealed that while the organization has a written central line maintenance policy
document, there is no systematic mechanism to verify that the policy elements are
performed correctly and completely during every patient-care interaction involving
central venous access. Specifically, the current system relies on individual nurse
judgment and memory to execute the seven components of the maintenance bundle
(hand hygiene, port disinfection with appropriate dwell time, sterile technique for
dressing changes, assessment of site integrity, documentation of necessity, timely
dressing changes based on manufacturer guidelines, and use of chlorhexidine-
impregnated dressings), without standardized visual cues, checklists, or real-time
verification systems. This lack of standardization creates variation in practice
based on individual nurse training background, workload pressures, interruptions
during care delivery, and differing interpretations of "appropriate" technique.
Further analysis revealed that the nursing staff turnover rate of 18% in the past year
resulted in a cohort of nurses with less than one year of ICU experience comprising
35% of the current MSICU workforce, and these nurses received abbreviated
onboarding during a period of staffing crisis that did not include competency
validation for central line maintenance beyond initial didactic instruction. The
absence of a forcing function or verification system means that protocol
deviations—whether due to knowledge gaps, time pressure, or workflow
interruptions—are not detected or corrected in real time, allowing non-compliant
practices to become normalized and perpetuating the conditions that enable
CLABSI development.
2B. Contributing Factors:
WGU D459 Task 3 Four Steps Tool Actual
Submission Example and Guide 2026/2027 |
Passed Assessment | Step-by-Step Template |
Pass Guarantee
PART 1: STEP ONE – DEFINING THE PROBLEM
1A. What is the problem?
The central venous catheter-associated bloodstream infection (CLABSI) rate in the
Intensive Care Unit (ICU) at Regional Medical Center has increased to 2.8
infections per 1,000 central line days over the past six months, which exceeds the
National Healthcare Safety Network (NHSN) benchmark of 1.0 per 1,000 central
line days and represents a 75% increase from the facility's baseline rate of 1.6 per
1,000 central line days established in the prior year. This elevated infection rate has
resulted in three preventable adverse patient events during the measurement period,
extended ICU length of stay for affected patients by an average of 7.2 days per
case, and generated approximately $132,000 in non-reimbursable costs associated
with treatment of hospital-acquired infections under current Centers for Medicare
& Medicaid Services (CMS) value-based purchasing penalties.
1B. Why is it a problem?
This problem poses significant threats across multiple dimensions of healthcare
quality and organizational performance. From a patient safety perspective,
CLABSIs are associated with mortality rates ranging from 12-25%, cause
substantial patient suffering through prolonged hospitalization and additional
invasive treatments, and represent a preventable harm that contradicts the
fundamental principle of "first, do no harm." For clinical staff, the elevated
infection rate creates moral distress among ICU nurses and physicians who are
committed to evidence-based practice, increases workload burden through complex
infection management protocols, and potentially indicates gaps in adherence to
established central line maintenance bundles that undermine professional practice
, 2
standards. At the organizational level, this problem directly impacts quality metrics
reported to regulatory agencies including The Joint Commission's National Patient
Safety Goal 07.04.01 for catheter-associated infection prevention, triggers financial
penalties under the CMS Hospital-Acquired Condition Reduction Program that can
reduce total Medicare reimbursement by 1%, damages the institution's reputation
in publicly reported Hospital Compare quality scores, and exposes the organization
to potential litigation risk. The Agency for Healthcare Research and Quality
(AHRQ) estimates that each CLABSI costs between $16,550 and $44,000 in
additional healthcare expenditure, none of which is reimbursable under current
payment models, creating a direct negative impact on the organization's financial
sustainability and its capacity to invest in quality improvement infrastructure and
staff development programs.
1C. What is the scope of the problem?
This problem is specifically scoped to the 24-bed medical-surgical intensive care
unit (MSICU) at Regional Medical Center, encompassing all three shifts (day,
evening, and night) and all patient populations requiring central venous access for
a duration exceeding 48 hours. The analysis includes patients with peripherally
inserted central catheters (PICCs), subclavian lines, internal jugular lines, and
femoral lines, but excludes dialysis catheters managed by the nephrology service
and temporary pacing wires managed by cardiothoracic surgery, as these fall under
separate protocols and surveillance systems. The temporal scope covers the six-
month period from October 2026 through March 2027, and geographically is
limited to the MSICU on the fourth floor; other ICU environments such as the
cardiovascular ICU, surgical ICU, and neonatal ICU are not included in this
analysis as they maintain separate nursing leadership, distinct patient populations,
and independent quality improvement structures. The process scope encompasses
central line maintenance practices including dressing changes, cap changes, tubing
changes, access port disinfection, and daily necessity assessments, but does NOT
include initial central line insertion procedures performed by physicians or
advanced practice providers, as insertion technique is governed by a separate
credentialing and competency system under medical staff bylaws. The stakeholder
scope includes ICU registered nurses, ICU nurse managers, infection
preventionists, intensivist physicians, and ICU clinical nurse specialists, but does
, 3
not extend to environmental services, pharmacy, or ancillary departments at this
phase of analysis.
PART 2: STEP TWO – IDENTIFYING CAUSES
2A. Primary Cause (Root Cause):
The fundamental root cause of the elevated CLABSI rate is the absence of a
standardized, enforceable central line maintenance bundle protocol that ensures
consistent adherence to evidence-based practices across all nursing shifts in the
MSICU. A root cause analysis conducted using the "Five Whys" methodology
revealed that while the organization has a written central line maintenance policy
document, there is no systematic mechanism to verify that the policy elements are
performed correctly and completely during every patient-care interaction involving
central venous access. Specifically, the current system relies on individual nurse
judgment and memory to execute the seven components of the maintenance bundle
(hand hygiene, port disinfection with appropriate dwell time, sterile technique for
dressing changes, assessment of site integrity, documentation of necessity, timely
dressing changes based on manufacturer guidelines, and use of chlorhexidine-
impregnated dressings), without standardized visual cues, checklists, or real-time
verification systems. This lack of standardization creates variation in practice
based on individual nurse training background, workload pressures, interruptions
during care delivery, and differing interpretations of "appropriate" technique.
Further analysis revealed that the nursing staff turnover rate of 18% in the past year
resulted in a cohort of nurses with less than one year of ICU experience comprising
35% of the current MSICU workforce, and these nurses received abbreviated
onboarding during a period of staffing crisis that did not include competency
validation for central line maintenance beyond initial didactic instruction. The
absence of a forcing function or verification system means that protocol
deviations—whether due to knowledge gaps, time pressure, or workflow
interruptions—are not detected or corrected in real time, allowing non-compliant
practices to become normalized and perpetuating the conditions that enable
CLABSI development.
2B. Contributing Factors:
